Dr. Laura Markley, a psychiatrist in the Division of Pediatric Psychiatry and Psychology at Akron Children’s Hospital, explains anxiety disorders in kids. Disorders can be hard to spot. But early identification and treatment is key.
Q: Anxiety disorders are among the most common mental health problems. Everyone experiences anxiety, so what distinguishes a disorder from normal anxiety?
A: Anxiety disorders are very, very common. About one in four teens will experience an anxiety disorder at some point in their life, and about one in 20 will experience a severe anxiety disorder.
Everyone feels anxious sometimes. But in an anxiety disorder, the anxiety tends to worsen over time and can interfere with important activities such as school, relationships and sleep.
Q: What are signs parents should look for?
A: Anxiety can be challenging to pick up on, because so much of what is experienced is “internal.” Unless a child can communicate their distress, which can be very difficult due to their age and developmental stage, it can be hard to identify until their functioning begins to decline.
Many children with anxiety disorders have a history of a somewhat anxious or shy disposition. It is developmentally normal for children to be wary of strangers and to not want to leave their parents when they are toddlers. If a child is experiencing significant, prolonged distress with separation – or unable to tolerate meeting new peers – this can be an early demonstration of anxiety that is outside of the norm.
In school-aged children, ongoing physical symptoms such as headache, stomachaches, nausea and vomiting may be a result of anxiety. Anxiety and/or depression should be considered if a physical cause for the symptoms is not apparent when taken to the doctor to evaluate these issues. Parents should know that in most cases these children are not “faking it” – their emotions are overloaded to the point that their body is “short-circuiting,” and they feel ill as a result.
Everyone experiences physical symptoms related to their emotions from time to time, for example when getting on a roller coaster, and maybe feeling your heart race or your stomach flip. But this is happening to a much larger degree for anxious kids because of the constant stress they are experiencing. Sometimes, when school is the stressor, the children miss a significant amount of school due to feeling ill, but they will feel better on the weekends. Having these children pulled out of school is not generally recommended because the children tend to become increasingly isolated and less functional. Treatment should focus on the goal of controlling anxiety and restoring regular school attendance.
Social anxiety is common in teens, and they begin to avoid activities in which they fear that they will be embarrassed, judged or rejected. Teens can become so overly focused on the response of their peers to what they wear, say or do, it can interfere with their ability to achieve in school because they are distracted from their schoolwork. This can lead parents to become concerned about ADHD because of falling grades; often it is found to be because the patient is anxious and/or depressed. They may also withdraw from activities they used to enjoy, like sports or a job. There may be noticeable changes in their normal appetite and/or sleep patterns. Frequent irritability or sadness are concerning, as depression and anxiety tend to occur together, so a child who is anxious can become depressed, and vice versa.
Q: But with adolescents experiencing so much change, uncertainty and emotional upheaval, isn’t it difficult to discern if they have an anxiety disorder?
A: Again, angst is something that just comes with the ever-changing world of the adolescent, and the real challenge of adolescence is adapting to these changes. An anxiety disorder impairs the adolescent’s ability to adapt to their environment. They become increasingly intimidated by it, which leads to worsened anxiety and a decline in their functioning.
Q: Does it run in families? Do anxious parents often pass on anxiety to their kids? What can parents do to break the cycle?
A: Just like every disorder, remember that there are genetic components and environmental components. Family history is a risk factor, but it is not definitive that a child will have anxiety if a parent does. Parents can moderate the environmental influence by making sure they care for their own anxiety because children learn to respond to situations by modeling their parents. It is also helpful to foster an environment where it is encouraged to be open about the benefits of receiving and accepting help when one needs it, especially with regard to mental health.
Q: What does treatment involve?
A: Treatment considerations for anxiety are psychotherapy and medication, with psychotherapy being the cornerstone of treatment. Your teen’s primary care physician is a great resource for recommendations and treatment for anxiety.
Therapy is often the first-line treatment for anxiety disorders. Cognitive behavioral therapies are very effective, especially for younger populations. These therapies teach a new way of interpreting and responding to issues and situations that drive the child’s anxiety. In cognitive behavioral therapy, adolescents are taught to sense their anxiety, stop, check their thoughts and confront the thoughts that are bringing on anxiety to gain better control. Adolescents and parents also learn about how they can use everyday activities as a way of soothing their anxieties and processing their worries — examples of these could include athletic or artistic activities, playing with pets or journaling.
Depending on the degree of impairment, medication may be appropriate in addition to treatment with therapy. If the anxiety is at a point where the teen can no longer interact successfully in their environment (significant school absence, quitting extracurricular activities, not leaving the house, etc.), or if they are experiencing depressive symptoms, then Selective Serotonin Re-Uptake Inhibitors (SSRIs), commonly called “antidepressants,” may be recommended. SSRIs are effective in treating the biological imbalances in the brain that contribute to anxiety. In general, sedating medications, such as benzodiazepines (Xanax, Ativan), are not recommended in treating anxiety disorders in youth, both because they can impair impulse control, learning and development in young brains, as well as having abuse/addiction potential.
Treatment works, but it takes time and patience. Just like any disorder, the earlier the child receives treatment, the better the overall prognosis is. A patient should sense improvement within a couple of months – sometimes sooner – and experience remission in 3-4 months with combination treatment. It’s very important to continue treatment for up to 18 months after remission to solidify the gains the teen makes and prevent relapses. Too often when things get better, an adolescent will stop going to therapy and taking their meds. This can lead to a rebound of their symptoms, which are sometimes worse than they originally were.
Q: If untreated, what are some of the consequences down the road?
A: Again, as with most health-related issues, the longer anxiety is left untreated, it worsens and becomes more challenging to treat. The longer a child has a maladaptive thinking or behavioral pattern, the more solidified it becomes. It grows more difficult to challenge those patterns in order to learn a new, healthier way of thinking or acting. The earlier these issues are addressed, the more likely the child is to be able to control their anxiety, and not vice versa.